Provider Demographics
NPI:1750446704
Name:KOCH, GARY C (DC)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:C
Last Name:KOCH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11959 PERRY HWY
Mailing Address - Street 2:
Mailing Address - City:WEXFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15090-8602
Mailing Address - Country:US
Mailing Address - Phone:724-934-0001
Mailing Address - Fax:724-934-5599
Practice Address - Street 1:11959 PERRY HWY
Practice Address - Street 2:
Practice Address - City:WEXFORD
Practice Address - State:PA
Practice Address - Zip Code:15090-8602
Practice Address - Country:US
Practice Address - Phone:724-934-0001
Practice Address - Fax:724-934-5599
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC004706L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1592870OtherHIGHMARK BC
PA075367Medicare ID - Type Unspecified